A Closer Look at The Center for Medicare & Medicaid Services’ Proposed Patient Safety Structural Measure

Patient safety is a critical component of healthcare quality. Despite significant advancements, preventable harm remains a significant concern in healthcare settings. The Centers for Medicare & Medicaid Services (CMS) has proposed a new Patient Safety Structural Measure (PSSM) to improve patient safety in hospital settings. This new quality measure will assess how hospitals implement safety improvement systems and evaluate hospital leadership’s commitment to patient safety. We at Beterra believe this is a proactive step towards continuous improvement and high reliability in patient care, and we are confident that it will significantly enhance patient safety.

A Quick Summary

In the proposed fiscal year (FY) 2025 Hospital Inpatient Prospective Payment (PPS) rule, CMS will introduce the Patient Safety Structural Measure (PSSM) for the Hospital Inpatient Quality Reporting (IQR) Program and the PPS- Exempt Cancer Hospital Quality Reporting (PCHQR) program. The PSSM is an attestation-based measure, meaning hospitals must affirmatively attest to having specific structures and practices in place that prioritize patient safety. The proposed reporting period will start in Calendar Year (CY) 2025 for Financial Year (FY) 2027 payment determination.

Crafted with input from a Technical Expert Panel and grounded in the “Safer Together: The National Action Plan to Advance Patient Safety,” it consists of the below five domains.

  1. Leadership Commitment to Eliminating Preventable Harm
  2. Strategic Planning & Organizational Policy
  3. Culture of Safety and Learning Health System
  4. Accountability & Transparency
  5. Patient & Family Engagement.

Each domain contains multiple statements that capture the essential structural and cultural elements of patient safety. Hospitals must affirmatively attest to all statements within a domain to receive a point for that domain. The maximum score is five (5) points, with one (1) point available per domain.  Under this proposal, CMS will publicly report the hospital’s performance score on these measures annually on Care Compare starting in the fall of 2026.

…More Beterra Analysis coming soon on PSSM.

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